Provider Demographics
NPI:1861414096
Name:MORENO, PEDRO (MD)
Entity type:Individual
Prefix:
First Name:PEDRO
Middle Name:
Last Name:MORENO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:1 GUSTAVE L LEVY PL
Mailing Address - Street 2:BOX 1030
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6500
Mailing Address - Country:US
Mailing Address - Phone:212-241-3497
Mailing Address - Fax:212-534-2845
Practice Address - Street 1:5 E 98TH ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6501
Practice Address - Country:US
Practice Address - Phone:212-241-5586
Practice Address - Fax:212-410-7196
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2013-12-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY001914174400000X
NY235294207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02460222Medicaid
NY02460222Medicaid